The discontinuation of Bexxar is an extreme example of a lifesaving drug being eliminated due to its relatively low profitability. In most cases, when a pharmaceutical company concludes that a niche drug is not making enough money, the product is sold to another, smaller company which continues to make it available. But continued availability is left to the discretion of the company (or companies) that owns the rights to the drug, which is how pharmaceutical companies can withhold potentially lifesaving experimental drugs that have not yet been approved by the FDA -- often, due to concerns that a potential problem resulting from such use could jeopardize the drug's ultimate approval.Luke Timmerman, on Xconomy.com, traces Bexxar's history:
Bexxar, developed in the late ‘90s by South San Francisco-based Coulter Pharmaceutical and acquired in 2000 by Seattle-based Corixa, had a lot going for it. The drug was aimed at a protein marker called CD20, which was already a validated molecular target for cancer, based on the success a couple years earlier of a so-called “naked” antibody from Genentech and Idec Pharmaceuticals, rituximab (Rituxan). Corixa had a well-respected CEO in Steve Gillis who attracted scientific talent, and raised lots of cash. It had a Big Pharma partner in Glaxo to help it manufacture and market the drug to the fullest.
Corixa, unable to turn Bexxar into a profit center, ended up being acquired by GlaxoSmithKline in 2005.
But there was a catch. Oncologists who saw these non-Hodgkin’s lymphoma patients could prescribe rituximab at an infusion center, along with chemotherapy. These doctors made money on every patient that went through their infusion center. Prescribing Bexxar meant they’d have to forgo that revenue stream, and refer the patient to a nuclear medicine pharmacy or radiation oncologist who could handle Bexxar or Zevalin.Are we to believe that the very people who were supposed to be saving patients walked away from a cure over profit? I'm trying hard not to... There were other factors, though:
“There were complicated logistics with having oncologists refer to another part of the healthcare system they normally didn’t interact with,” Rivera says. “We couldn’t get them to change their habits. The doctor would usually say ‘Oh, I’ll give the patient another course of R-CHOP’ (Rituxan plus a specific chemo regimen) instead.”
Younes, the chair of lymphoma at Memorial Sloan-Kettering, has heard the story about oncologists rejecting Bexxar because they didn’t want to refer patients to medical centers that might be seen as competitors. He says that point is “exaggerated” and notes that oncologists refer patients to other specialists all the time. He points to other problems with Bexxar’s commercialization. “It’s almost a comedy of errors,” he says.
There was a muddled clinical trial strategy, Younes said. Multiple trials were opened up to expand Bexxar usage, which may have been well-intended, but the plan ended up confusing physicians about where the drug was most useful, Younes said. A lot of clinical trials were sponsored, making it possible for many patients who might have paid to get the drug to instead get it for free. Then at one point, Glaxo abruptly shut down all the trials, Younes said.So what constitutes bad sales? Reno gives us the numbers:
“They ended up pissing off a lot of people,” he said.
There were headaches in manufacturing an antibody that was linked to radiation. The radioactive piece of the drug came from a supplier in Canada, and the occasional snowstorm would throw the whole supply chain out of whack, causing patients infusions to be delayed, Rivera said. That was a big inconvenience for some patients who sometimes had to drive hours for a scheduled infusion at a big academic medical center, Rivera said.
While Bexxar saved this writer’s life in a clinical trial in 1999 with virtually no side effects and has saved many other lives, sales of the drug did not meet GSK’s expectation. Catalina Loveman, GSK’s director of U.S. external communications, oncology, told IBTimes that total sales of Bexxar in 2012 in the U.S. and Canada were approximately $1 million; for comparison, the blockbuster drug Viagra earned Pfizer a reported $2.05 billion in sales in 2012.Everything is relative. I guess it didn't occur to GSK that those who survive lymphoma might eventually become Viagra customers. Oh, well. I guess a few thousand lives pale in comparison to a few million...well, need I say it?
Like Bexxar, Zevalin has also struggled in the marketplace. In the third quarter 2013, Zevalin’s profits were $8 million. But unlike GSK, Spectrum Pharmaceuticals, makers of Zevalin, is committed to keeping this drug on the market.
“What is happening with Bexxar is virtually unprecedented,” said Spectrum’s chief operating officer, Ken Keller, who came to Spectrum a year and a half ago from California-based Amgen, the world's largest independent biotech company. “I do not know of a single example of a drug company that has walked away from a drug that is this effective. Typically, when a company gives up on a treatment that works this well, they will a find a smaller company to sell it.”
Keller acknowledged that neither Bexxar nor Zevalin has been able to break through and become the blockbuster drugs that he says they both should be.
“I’ll be honest: We don’t gain a lot of value from Zevalin,” he said. “We have the data that shows how well it works, but it has still not caught on with many doctors. However, Spectrum will continue to manufacture Zevalin because our CEO [Raj Shrotriya] is on a mission to make RIT the standard of care for lymphoma in the U.S.. If this were only about finances, it could lead to different decision. But this treatment saves lives, and we believe we have an obligation to cancer patients. They deserve to have access to it.”
As much as I dislike being a patient, I have to admit it’s a good experience for a health care professional to go through. To be on the receiving end of the healthcare system not only helps me develop compassion for patients and families, but it also gives me a clearer vision of what we’re doing right and what we need to work on when delivering care. And it’s also given me some insight into patient satisfaction vs. patient-centered care.
A month or so ago I wrote a post on patient satisfaction scores and how health care providers are focusing on improving those scores, sometimes to the dismay of clinicians. I now have the opportunity to experience the health care system as a patient and be a satisfied or a dissatisfied consumer (or somewhere in between).
Recently, I paid visit to a dietitian and diabetes nurse educator because of a diagnosis of gestational diabetes. I was told to call the hospital’s central scheduling department to make the appointments. When I did, I was given two different dates two weeks apart, the first with the diabetes educator and the second two weeks later with the dietitian. I was given a long explanation about how the hospital was under construction and the bridge to the main hospital was closed, which is why I needed to enter through the medical office building entrance. It was also advised that I come 45 minutes early.
Then over the next few days I received follow-up calls from the scheduling department regarding the two appointments. When I returned the calls, a different employee took my call and wasn’t sure what the follow-up was regarding. I had assumed it was just to verify the times two weeks apart.
When I showed up for my appointment I followed the instructions then realized I was never given a suite number for the visit. I did my best to guess which one it was, but they were all closed. Why did I need to be there 45 minutes in advance? Perhaps I needed to stop in main hospital’s registration department first, after all they did mention something about the bridge being closed. So I got in my car and drove over to registration where I sat for 15 minutes before they called me over to discover that I had been in the right spot in the first place and I should go back. As I readied to get back into my car I asked what the suite number was. The registration employee had no idea and had to call the educator’s office to find out.
Once I settled in for my appointment, the educator asked about the instructions I was given and I told her I wasn’t given a suite number and was told to come 45 minutes early. She was none too pleased to hear that. Then she informed me that my appointment with the dietitian was immediately following my appointment with her. So that’s what the scheduling department was calling about! I told her that was great but I had no idea. She also told me that the employees in central scheduling could not see the same scheduling screen as the folks in the diabetes center and often did not know that earlier appointments were available.
Was this a satisfying experience? Not really. But the clinical care from the educator and dietitian was very good. They really listened when I explained how I felt about being there (annoyed at the diagnosis) and worked to try to come up with an eating and glucose testing schedule that fit my night shift job. After seeing them I knew what to do, when to do it, and who to call if something was off. With their focus on my needs, they were providing patient-centered care.
If asked if I was satisfied with my experience how would I respond? The scheduling process could have used some work but the clinical care was quite good.
This experience got me thinking about patient satisfaction and patient-centered care and how there is a distinct difference between the two. The writers of a July 2012 JAMA article Patient Satisfaction and Patient-Centered Care Necessary but Not Equal share my opinion.
Patient-centered care, as defined by the Institute of Medicine in its 2001 report Crossing the Quality Chasm, is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions,” whereas the JAMA authors explain, patient satisfaction is based on consumer marketing and measures the quality of the service against the consumer’s expectations.
As pointed out in the 2011 article The Values and Value of Patient-Centered Care in the Annals of Family Medicine, what some hospitals have been calling patient-centered care is “superficial and unconvincing.” Things like greeters and hotel-like decor “might enhance the patient’s experience, they do not necessarily achieve the goals of patient-centered care.”
When looking at my experience, the scheduling department did not meet my expectations — to give the appropriate information like suite number and arrival time. Yes, I was not satisfied with the scheduling experience but not getting the correct information did not harm me in any way. However, if the diabetes center had not taken my unique situation into account and given me a health regime that fit my night shift schedule, then my health outcomes could have been compromised. Had I gotten the correct scheduling information but not appropriate clinical care, in theory I could have been happy but not as healthy.
In an opinion piece in Circulation: Cardiovascular Quality and Outcomes, the author writes that satisfied patients can still have poor clinical results, though more research on the correlation between patient-satisfaction, patient-centered care and patient outcomes needs to be done.
I agree and would also argue that when health care providers focus on patient-centered — because patients feel heard and valued with this type of care — high satisfaction scores will follow. Plus, there will be better patient outcomes when patients are participating in their care. If you had to pick one area to focus on, patient satisfaction vs. patient-centered care, I’d focus on patient-centered care.
Two resources to help providers achieve patient-centered care are The Journal of General Internal Medicine‘s A 2020 Vision of Patient-Centered Primary Care and Plantree’s Patient-Centered Care Improvement Guide. Both help providers assess their implementation of patient-centered care and give pointers on how to improve care delivery.
Perhaps it’s because I have always worked in the clinical setting that I believe good clinical care can trump, or at least balance, parts of an experience that are less satisfying. Healthy patients equal happy patients and I feel they, like me, would be more willing to compartmentalize different aspects of the care experience. Because they are treated like individuals and listened to by their clinicians, they’ll be less likely to give an overall poor satisfaction score if something, like scheduling, goes amiss. And let’s not forget that despite how health care has changed over the years, good health outcomes are really what it is all about.
In various conversations on how to improve patient care, the importance of health literacy is often raised. Health literacy is needed as it relates to effective patient engagement and healthy habits. Information and knowledge create greater awareness of how to live healthier and interact with doctors in a more meaningful way.
Another element of health literacy needs to include health IT literacy. With about 78% of care providers now using electronic health records (EHR) and wearable technology gaining momentum, healthcare is moving into the digital age. Patients will not need go deep into the technology, but a base understanding will be required.
Although this is not a complete list, we need to begin somewhere. Highlighted below are some basic health IT elements to raise the literacy levels of patients.
Affordable Care Act: This law generates intense feelings and debate. The Medicaid.gov site defines the Affordable Care Act in this way:
“…provides Americans with better health security by putting in place comprehensive health insurance reforms that will:
Hold insurance companies accountable,
Lower health care costs,
Guarantee more choice, and
Enhance the quality of care for all Americans.”
Essentially, the Affordable Care Act expands Medicaid coverage to low-income individuals and works toward adding improvements to our healthcare system. Read more about your healthcare rights here.
HITECH / Meaningful Use: In health IT circles, most will know what Meaningful Use is and where it came from. Move outside this circle and most will just think the drive to electronic health record adoption is a part of the Affordable Care Act (Obamacare). Meaningful Use was born out of the American Recovery and Reinvestment Act of 2009 (aka Stimulus bill) in which the Health Information Technology for Economic and Clinical Health (HITECH) was buried. Meaningful Use is a part of HITECH and, together, they seek:
“…to improve American health care delivery and patient care through an unprecedented investment in health information technology. The provisions of the HITECH Act are specifically designed to work together to provide the necessary assistance and technical support to providers, enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure the workforce is properly trained and equipped to be meaningful users of EHRs.”
Simply stated, HITECH/Meaningful Use is an incentive program to move patient records from paper to an electronic format, which will then enable secure, efficient exchange of patient data, and provide patients easier access to their records.
EHR – Electronic Health Record: According to the HealthIT.gov website:
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.”
An important element to an EHR is it contains all relevant patient information from different clinicians involved in a patient’s care.
PHR – Personal Health Record: According to American Health Information Management Association (AHIMA),
“The PHR is a tool that you can use to collect, track and share past and current information about your health or the health of someone in your care. Sometimes this information can save you the money and inconvenience of repeating routine medical tests. Even when routine procedures do need to be repeated, your PHR can give medical care providers more insight into your personal health story.”
Patients own and manage their health data – you own it, you maintain it. Having the ability to electronically receive relevant data from care providers in a usable, efficient way is very helpful.
HIPAA – Health Insurance Portability and Accountability Act: Finding a concise definition for HIPAA is challenging. On HHS.gov, the following explanation is good:
“Most of us believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals’ protected health information, whether electronic, written, or oral. The Security Rule is a Federal law that requires security for health information in electronic form.”
Even better, watch this quick video:
Your rights include saying who can see your data from clinical visits, and providers are responsible for securing your data collected during these visits.
PHI – Protected Health Information: Since protected health information was used in the HIPAA definition, we should address it. The National Institutes of Health highlights PHI as “individually identifiable health information that is transmitted or maintained in any form or medium (electronic, oral, or paper) by a covered entity or its business associates, excluding certain educational and employment records.”
Essentially, PHI is your health data.
Quantified Self: There is much more health data available because there are more tracking devices to use. Quantified Self, or wearable tech, are interchangeable terms and what it means you are proactively tracking (quantifying) your health metrics. Watches, mobile phones, apps, and other devices make the recording of your daily health information easy.
By tracking your health status, the objective is to understand your healthy habits and their impact as well as keep chronic conditions monitored and stable.
With better and timelier data, your health patterns are recognized and can be adjusted more effectively, as needed. Think diet, exercise, blood sugar, heart rate, and much more… recorded, tracked, and shared as you define.
Interoperability: Inevitably in health IT conversations, the lack or challenge of sharing patient data between providers, applications, and devices will arise. Healthcare has many data standards (e.g., HL7, X12) and different communication protocols (e.g., TCP/IP, Direct Project, Web Services).
For data to flow, each application vendor needs to open up their application or device to send and receive data. After this, the data differences need to be understood and then mapped. Integration solutions exist to orchestrate this patient data flow, but the considerations are many: application perimeters, privacy and security requirements, data specifications, workflow necessities, and more.
Interoperability is achievable and, as a patient, requesting your data in an electronic, secure way will help facilitate this requirement.
When health IT literacy works, it looks like a more fully engaged patient. The flow of health IT literacy may look like the illustration below. Pieces of the healthcare puzzle begin to fit together and patients have a broader perspective of how it all fits together, along with their important role within the healthy flow.
Healthcare has many components and, ultimately, the most essential elements are delivering high quality care in a timely and efficient manner. In the middle of this is you – the patient. Understanding what is healthy is core to health literacy. Understanding how your data is collected, stored, used, and exchanged is central to health IT literacy. We need to raise our health standards for both healthcare and health IT literacy, and this will take a community and your active participation.
What other key elements are required to raise health IT literacy? Add your thoughts and let’s expand this list to what is important for patients to grasp and use.
I’m a big fan of the online world. I love the ease of online banking, the efficiency of Zappos shoe shopping, and the simplicity of reading The Drudge Report for all the latest news. Someday I may also be a huge enthusiast for online patient portals, but that’s not quite the case today.
During the workday I rarely think about mundane tasks such as scheduling physicals or calling the eye doctor to order new contacts. I am more likely to recall that my daughter needs a follow-up appointment with the ENT when I notice her taking off her hearing aid for the night. Or, I’ll remember it’s time for a mammogram while sharing a bottle of wine with girlfriends and someone mentions the joys of her most recent scan. That last one happens a lot, actually.
I’d like to think I am the quintessential candidate for online patient portals: busy single mom who works full-time and is tech-savvy. I have little patience for being placed on hold for 10 minutes while listening to an endlessly looping recording about the importance of my call. I’d much rather schedule a doctor’s appointment with a few clicks on my keyboard while sipping my first cup of coffee. I get annoyed when my only communication option is to wait until the office opens at 9:00 a.m., navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.
Recently I had a very positive experience using my primary care physician’s patient portal. One of my specialists requested a copy of my PCP’s referral form in order to schedule a new appointment. I accessed the PCP’s patient portal and in about two minutes found the referral and requested a copy to be forwarded to the specialist. The next day the specialist’s office called to say they had the referral in hand.
Other recent patient portal attempts have been a bit less successful. Typically if I need to schedule any type of medical appointment, I first go to the practice’s website and determine if they have an online scheduling option. That’s what I did a couple of months ago to schedule an appointment for my daughter and the whole process worked beautifully: the system asked for my preferred days and times; the next day I had an email informing me to check to practice’s portal for a message; the message informed me of the appointment time, which I then confirmed.
Unfortunately, a couple of days later my daughter reminded me of a conflict. So, back to the portal I went to send a new message requesting a reschedule. After several days I realized no one had responded to my message. I sent a second message. Again, no response. I ended up having to call the office, navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.
Another one of my physicians uses a patient portal but its functionality is limited. For example, I am able to request an appointment with preferred dates and times, but rather than having an automated response, someone calls me back to finalize the appointment time. It beats having to call the office and being placed on hold, but if I miss the call or am driving, it’s back to the old-fashioned telephone method.
I often hear providers complain about the Stage 2 Meaningful Use requirement that at least five percent of patients view or download their personal health information via an online portal. Many argue the threshold is too high because many patients lack Internet access or computer expertise, or simply prefer communicating with a live person. However, I’d contend that providers are not doing themselves any favors by implementing poorly designed portals with limited functionality. As a patient, I wonder why I should use a portal if it doesn’t eliminate having to call the practice. I worry that my messages are getting “lost” – either due to technical glitches or office workflow issues. I get frustrated with confusing navigation and functionality that can’t hold a candle to what my veterinarian offers.
In a world where we can spend 10 minutes online and pay a month’s worth of bills, buy a pair of shoes, and read the day’s headlines, why is the healthcare industry so far behind in its efforts to provide patients with a consistently efficient online experience?
Healthcare executives are continuously evaluating the subject of RFID and RTLS in general. Whether it is to maintain the hospitals competitive advantage, accomplish a differentiation in the market, improve compliance with requirements of (AORN, JCAHO, CDC) or improve asset utilization and operating efficiency. As part of the evaluations there is that constant concern around a tangible and measurable ROI for these solutions that can come at a significant price.
When considering the areas that RTLS can affect within the hospital facilities as well as other patient care units, there are at least four significant points to highlight:
Disease surveillance: With hospitals dealing with different challenges around disease management and how to handle it. RTLS technology can determine each and every staff member who could have potentially been in contact with a patient classified as highly contagious or with a specific condition.
Hand hygiene compliance: Many health systems are reporting hand hygiene compliance as part of safety and quality initiatives. Some use “look-out” staff to walk the halls and record all hand hygiene actives. However, with the introduction of RTLS hand hygiene protocol and compliance when clinical staff enter or use the dispensers can now be dynamically tracked and reported on. Currently several of the systems that are available today are also providing active alters to the clinicians whenever they enter a patient’s room and haven’t complied with the hand hygiene guidelines.
Locating equipment for maintenance and cleaning:
Having the ability to identify the location of equipment that is due for routine maintenance or cleaning is critical to ensuring the safety of patients. RTLS is capable of providing alerts on equipment to staff.
A recent case of a hospital spent two months on a benchmarking analysis and found that it took on average 22 minutes to find an infusion pump. After the implementation of RTLS, it took an average of two minutes to find a pump. This cuts down on lag time in care and can help ensure that clinicians can have the tools and equipment they need, when the patient needs it.
There are also other technologies and products which have been introduced and integrated into some of the current RTLS systems available.
There are several RTLS systems that are integrated with Bed management systems as well as EHR products that are able to deliver patient order status, alerts within the application can also be given. This has enabled nurses to take advantage of being in one screen and seeing a summary of updated patient related information.
Unified Communication systems:
Nurse calling systems have enabled nurses to communicate anywhere the device is implemented within the hospital facility, and to do so efficiently. These functionalities are starting to infiltrate the RTLS market and for some of the Unified Communication firms, it means that their structures can now provide a backbone for system integrators to simply integrate their functionality within their products.
In many of the recent implementations of RTLS products, hospital executives opted to deploy the solutions within one specific area to pilot the solutions. Many of these smaller implementations succeed and allow the decision makers to evaluate and measure the impacts these solutions can have on their environment. There are several steps that need to be taken into consideration when implementing asset tracking systems:
• Define the overall goals and driving forces behind the initiative
• Develop challenges and opportunities the RTLS solution will be able to provide
• Identify the operational area that would yield to the highest impact with RTLS
• Identify infrastructure requirements and technology of choice (WiFi based, RFID based, UC integration, interface capability requirements)
• Define overall organizational risks associated with these solutions
• Identify compliance requirements around standards of use
RFID is one facet of sensory data that is being considered by many health executives. It is providing strong ROI for many of the adapters applying it to improve care and increase efficiency of equipment usage, as well as equipment maintenance and workflow improvement. While there are several different hardware options to choose from, and technologies ranging from Wi-Fi to IR/RF, this technology has been showing real value and savings that health care IT and supply chain executives alike can’t ignore.
It was not long after mankind invented the wheel, carts came around. Throughout history people have been mounting wheels on boxes, now we have everything from golf carts, shopping carts, hand carts and my personal favorite, hotdog carts. So you might ask yourself, “What is so smart about a medical cart?”
Today’s medical carts have evolved to be more than just a storage box with wheels. Rubbermaid Medical Solutions, one of the largest manufacturers of medical carts, have created a cart that is specially designed to house computers, telemedicine, medical supply goods and to also offer medication dispensing. Currently the computers on the medical carts are used to provide access to CPOE, eMAR, and EHR applications.
With the technology trend of mobility quickly on the rise in healthcare, organizations might question the future viability of medical carts. However a recent HIMSS study showed that cart use, at the point of care, was on the rise from 26 percent in 2008 to 45 percent in 2011. The need for medical carts will continue to grow; as a result, cart manufacturers are looking for innovative ways to separate themselves from their competition. Medical carts are evolving from healthcare products to healthcare solutions. Instead of selling medical carts with web cameras, carts manufacturers are developing complete telemedicine solutions that offer remote appointments throughout the country, allowing specialist to broaden their availability with patients in need. Carts are even interfaced with eMAR systems that are able to increase patient safety; the evolution of the cart is rapidly changing the daily functions of the medical field.
Some of the capabilities for medical carts of the future will be to automatically detect their location within a healthcare facility. For example if a cart is improperly stored in a hallway for an extended period of time staff could be notified to relocate it in order to comply to the Joint Commission’s requirements. Real-time location information for the carts could allow them to automatically process tedious tasks commonly performed by healthcare staff. When a cart is rolled into a patient room it could automatically open the patient’s electronic chart or give a patient visit summary through signals exchanged between then entering cart and the logging device kept in the room and effectively updated.
Autonomous robots are now starting to be used in larger hospitals such as the TUG developed by Aethon. These robots increase efficiency and optimize staff time by allowing staff to focus on more mission critical items. Medical carts in the near future will become smart robotic devices able to automatically relocate themselves to where they are needed. This could be used for scheduled telemedicine visits, the next patient in the rounding queue or for automated medication dispensing to patients.
Innovation will continue in medical carts as the need for mobile workspaces increase. What was once considered a computer in a stick could be the groundwork for care automation in the future.
This has been an eventful year for speech recognition companies. We are seeing an increased development of intelligence systems that can interact via voice. Siri was simply a re-introduction of digital assistants into the consumer market and since then, other mobile platforms have implemented similar capabilities.
In hospitals and physician’s practices the use of voice recognition products tend to be around the traditional speech-to-text dictation for SOAP (subjective, objective, assessment, plan) notes, and some basic voice commands to interact with EHR systems. While there are several new initiatives that will involve speech recognition, natural language understanding and decision support tools are becoming the focus of many technology firms. These changes will begin a new era for speech engine companies in the health care market.
While there is clearly tremendous value in using voice solutions to assist during the capture of medical information, there are several other uses that health care organizations can benefit from. Consider a recent product by Nuance called “NINA”, short for Nuance Interactive Natural Assistant. This product consists of speech recognition technologies that are combined with voice biometrics and natural language processing (NLP) that helps the system understand the intent of its users and deliver what is being asked of them.
This app can provide a new way to access health care services without the complexity that comes with cumbersome phone trees, and website mazes. From a patient’s perspective, the use of these virtual assistants means improved patient satisfaction, as well as quick and easy access to important information.
Two areas we can see immediate value in are:
Customer service: Simpler is always better, and with NINA powered Apps, or Siri like products, patients can easily find what they are looking for. Whether a patient is calling a payer to see if a procedure is covered under their plan, or contacting the hospital to inquire for information about the closest pediatric urgent care. These tools will provide a quick way to get access to the right information without having to navigate complex menus.
Accounting and PHR interaction: To truly see the potential of success for these solutions, we can consider some of the currently used cases that NUANCE has been exhibiting. In looking at it from a health care perspective, patients would have the ability to simply ask to schedule a visit without having to call. A patient also has the ability to call to refill their medication.
Nuance did address some of the security concerns by providing tools such as VocalPassword that will tackle authentication. This would help verify the identity of patients who are requesting services and giving commands. As more intelligence voice-driven systems mature, the areas to focus on will be operational costs, customer satisfaction, and data capture.
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Melissa McCormack, a medical researcher with EHR consultancy group Software Advice, recently published their medical practice management BuyerView research, which found that 63% of the buyers were replacing existing PM solutions, rather than making a first-time purchase. This mirrors the trend we’ve seen across medical software purchasing, where the HITECH Act may have prompted hasty first purchases of EHR solutions, followed by replacements 1-2 years later. For PM vendors, this means there’s a huge opportunity to market your products to practices as an upgrade, even if they’re already using PM software. I reached out to Melissa to ask her to elaborate on the implications of the trends she found in her recent research. Here’s some advice for vendors and solutions providers.
1. As EHR meaningful use requirements grow more involved, standalone billing or scheduling systems are becoming less viable. In fact, nearly 70 percent of the buyers we spoke with wanted integration between practice management and EHR. The trend of PM buyers looking for robust EHR integration grows more pronounced each year, and shows no signs of tapering off since EHR meaningful use requirements increasingly require physicians to utilize charting, billing and scheduling in tandem. Vendors who can offer seamless integration between these applications will have a clear advantage over those who cannot.
2. Another regulatory pressure influencing PM software replacement is ICD-10. Compliance with the new code set is a major driver not only of practice management purchases in general, but specifically of replacements—25% of buyers replacing an existing solution cite a concern that their current solution wouldn’t support the code set switch. Despite the implementation deadline having been extended to October 2015, we’re seeing practices give a lot of thought to preparation, and they’re realizing the software they use will play a major role in their own readiness. Vendors who are confident in their ICD-10 readiness should take care to communicate that confidence to their existing users, as well as marketing it to prospective customers.
3. The medical practice management software buyers we talk to clearly prefer cloud-based systems. Among buyers with a preference, 88% want cloud deployment. We’re hearing from smaller practices that they value the low up-front costs, as well as not needing to maintain servers and dedicated IT staff. Additionally, buyers appreciate the remote access options afforded by cloud solutions. Some buyers even seem to conflate “cloud” with “remote access” and “mobile access” (even though those features aren’t unique to cloud-based products), suggesting these are the features of cloud-based software they are most concerned with. In fact, almost 20% of buyers identified mobile access as a top priority. Vendors who offer mobile support are at an advantage and should highlight their capabilities prominently.
4. Practice management software buyers come from diverse roles within practices. We saw clinicians and administrative staff represented almost equally—46% and 40%, respectively—among our buyer sample. Vendors should consider their audiences when marketing their products and tailor communication accordingly, giving equal weight to the unique benefits for clinicians and administrators.
I recently saw a demo of the Decisions.com platform and left impressed with the workflow engine, business rules execution, forms automation, and data integration platform. I’m very familiar with almost all the major HL7 routers and integration engines out there but Carl Hewitt, Founder and Chief Architect at Decisions, is releasing something fairly unique — an visual HL7 interface definition and integration platform for use by analysts and non-technical personnel charged with healthcare data connectivity across business workflows. I found their approach unique enough that I’ll be something that I don’t do often — a review. But, before I post the review in the coming days, I reached out to Carl to help set the stage and share the most common questions and answers we get about HL7.
What is HL7?
HL7 is how healthcare applications talk to each other – for example, when a patient is admitted to a facility, when a patient schedules an appointment, when a lab test is ordered, or when a medication is prescribed an HL7 message can be sent from one system to another. HL7 is what disparate systems use to tell each other about patient activity. HL7 is a widely adopted text based communications standard created in 1987 that can run on almost all modern hardware and software systems that support the standard.
The HL7 specification is governed by Health Level Seven International, a not-for-profit, ANSI-accredited standards developing organization.
How do HL7 systems communicate?
HL7 is human readable text that is broken up into meaningful sections and sent as data packets from application to application across well defined communication mechanisms with handshaking and acknowledgement procedures. Because the data is sent over widely adopted communication mechanisms in a readable format (i.e., text that can be opened on any computer), HL7 tends to work pretty well.
What are the various components of HL7 messages?
Like any technology, HL7 uses a glossary of specific terms that have specific meaning. While an interface engine alleviates the need to directly integrate with all of these concepts, understanding them will help you know what the HL7 engine is actually doing.
HL7 has evolved over many years and new events have been added to the standard that weren’t there in previous versions. For instance, an ADT A01 (ADT Patient Admit) and an ADT A08 (ADT Patient Data Update) were initially defined as different message types, but later combined. So, a message that comes in as an ADT A08 in version 2.5 of HL7 will actually have the structure of an ADT A01, however, because it is sent as an A08 – the meaning of the message will be an update. Confusing? No worries, most interface engines hide this fact and make you think you are still getting an A08.
Some interfaces are one way – they either send data to another system or listen to data from another system. Most interface engines or interface technologies support sending and receiving data as these technologies normally sit in between two medical systems and modify the messages as they are sent. Different interface engines might have functionality to transform or route messages attached to interfaces.
How are HL7 text messages transmitted?
There are two primary technologies used to send message in most healthcare applications: TCP and Files.
What does an HL7 Message Look like?
HL7 messages are made up of segments. Each carrying specific information about anything from a patient’s name to an allergy, a radiology image, a transcript, etc.
MSH|^~\&|MegaReg|XYZHospC|SuperOE|XYZImgCtr|20060529090131-0500||ADT^A01|01052901|P|2.5 EVN||200605290901||||200605290900 PID|||56782445^^^UAReg^PI||KLEINSAMPLE^BARRY^Q^JR||19620910|M||2028-9^^HL70005^RA99113^^XYZ|260 GOODWIN CREST DRIVE^^BIRMINGHAM^AL^35 209^^M~NICKELL’S PICKLES^10000 W 100TH AVE^BIRMINGHAM^AL^35200^^O |||||||0105I30001^^^99DEF^AN PV1||I|W^389^1^UABH^^^^3||||12345^MORGAN^REX^J^^^MD^0010^UAMC^L||678 90^GRAINGER^LUCY^X^^^MD^0010^UAMC^L|MED|||||A0||13579^POTTER^SHER MAN^T^^^MD^0010^UAMC^L|||||||||||||||||||||||||||200605290900 OBX|1|NM|^Body Height||1.80|m^Meter^ISO+|||||F OBX|2|NM|^Body Weight||79|kg^Kilogram^ISO+|||||F AL1|1||^ASPIRIN
In the message above you’ll notice some things that are ‘bold’ to call your attention to them.
What type of data does HL7 Transmit?
The HL7 specification is fairly comprehensive. It contains data about many aspects of health care and data including patients, schedules, appointments, interactions between providers and patients, insurance information, information on diagnoses and procedures, medical records and much more. If an application is configured to receive all messages of all types from another application, it is likely that much of the data that is received is not relevant to what is needed. For instance, if I have a scheduling application, it might not be relevant for me to get information on updates of patient allergies – but changes to patient demographic information is very important.
What are challenges with HL7 in the Healthcare Enterprise?
A growing challenge with contemporary Healthcare IT Solutions is the “app-centric” approach many vendors are taking to solving problems. With more and more of these enterprise apps being designed as standalone systems, Healthcare IT teams are faced with unique integration challenges involving sensitive patient health information.
Many teams are trying to figure out how to implement a data layer that can bring all of the healthcare provider systems (billing, lab, patient, etc.) and partner systems together so each has access to the data that it needs. Some are taking home grown approaches with custom message services and open source technologies. Others are discovering a new breed of data management tools. Let’s take a closer look at what some of the primary tools have been and what some of the new tools look like.
There are a number of unique challenges to handling a standard driven data structure such as:
Zach Watson over at Technology Advice.com wrote a nice piece on EHR Trends in Nashville. I’m not a big fan of “trends” articles because trends aren’t that important, the implications of those trends and how to operationalize the implications are most important. I enjoyed Zach’s article so I asked him to tell us what those trends mean for EHR buyers and health IT vendors writ large. Here’s what Zach said:
Our study of office-based physicians across the city of Nashville to gain insight into which EHR systems they were using, as well as how pleased they were with their systems revealed these insights:
We chose to survey Nashville because of the city’s vibrant technology market, which includes an eclectic healthcare IT industry subset. Spotlighted in the Wall Street Journal, Nashville’s healthcare market features billion dollar organization Hospital Corporation of America, and has played host to over a billion dollars of investment capital in the last decade.
For buyers of electronic medical records, several key points can be taken from the results of the study.
For specialists, a mix of specialty specific products and highly customizable options has led to higher satisfaction than previously recorded averages. For example, 75 percent of dentists in Nashville use a best of breed system, such as Dentrix or Patterson Eaglesoft. The Satisfaction of dentistry EHR users was 8.5/10: significantly higher than previously tallied national averages. Not only do best of breed EHRs still have a place in the market, it seems that providers who chose such platforms realize high satisfaction rates.
However, it’s not quite as simple as just choosing a best of breed platform. Many other specialties – from Radiology, to Pulmonary Disease, to ENTs and Podiatry – reported using eClinicalworks, the market leader in Nashville. These providers were mostly satisfied with their selection as well as eClinicalWorks averaged an 8.5/10 satisfaction rate, leaving one to wonder what the answer truly is: a more general platform, or a best of breed solution.
Examining eClinicalWorks platform can provide some insight. Specialty EHRs are defined by their alignment with the workflow of a particular type of physician, particularly in the charting feature. Basically, good templates can result in satisfied users. Though eClinicalworks services a broad market, it has a particularly robust customization feature. Branded eCliniSense, this function stores information about past diagnoses, such as labs and diagnostic imaging orders, which can then be used to construct ordersets (in this context synonymous with templates) based on usage data. This feature can make creating customized templates much easier, which can allow providers to speed up their work, rather than struggling to populate the same fields over and over again.
To be clear, eClinicalWorks is not the only software to feature highly customizable templates, but given the diversity of specialists that use it in the Nashville market it’s clear that if specialists don’t go with a best of breed platform, they should seek a platform with customizable modules and templates.
Essentially, they should find a system that lets them create their own best of breed solution.
Another surprising finding was the absence of Epic in Nashville’s office-based physician population, as well as Practice Fusion’s prominence (it has the second-highest market share). These results seem to suggest that price is a large factor in EHR purchases in the Nashville market.
Epic is renowned for its high prices, so much so that it makes for good headlines. Practice Fusion is free, and is increasing its market share on a national level at a faster pace than any other vendor (this is also supported by its strong showing in the Nashville market). Of Practice Fusion users in Nashville, 20 percent were on their second EHR, again indicating that the price of this cloud-based vendor may have been an incentive (especially if they had lost money on their last EHR investment).
Providers are often admonished not to let price rule their EHR buying process, but the Commonwealth Fund’s recent study found that small and single physician practices lag behind other EHR populations in terms of adoption. What’s slowing them up? Price.
Despite Meaningful Use incentive money, EHRs are still not cheap, and federal subsidies don’t cover the productivity loss or drop in quality scores that sometimes accompany the shift from paper to digital records. EHRs like Practice Fusion and Kareo are offering free models that these small practices can afford. Depending on which source you trust – the National Center for Healthcare Statistics’s 78 percent or SK&A’s 61 percent – the number of providers adopting EHRs has reached a tipping point, and the laggards are balking at the price.
“Large collections of electronic patient records have long provided abundant, but under-explored information on the real-world use of medicines. But when used properly these records can provide longitudinal observational data which is perfect for data mining,” Duan said. “Although such records are maintained for patient administration, they could provide a broad range of clinical information for data analysis. A growing interest has been drug safety.”
In this paper, the researchers proposed two novel algorithms—a likelihood ratio model and a Bayesian network model—for adverse drug effect discovery. Although the performance of these two algorithms is comparable to the state-of-the-art algorithm, Bayesian confidence propagation neural network, by combining three works, the researchers say one can get better, more diverse results.
I saw this a few weeks ago, and while I haven't had the time to delve deep into the details of this particular advance, it did at least give me more reason for hope with respect to the big picture of which it is a part.
It brought to mind the controversy over Vioxx starting a dozen or so years ago, documented in a 2004 article in the Cleveland Clinic Journal of Medicine. Vioxx, released in 1999, was a godsend to patients suffering from rheumatoid arthritic pain, but a longitudinal study published in 2000 unexpectedly showed a higher incidence of myocardial infarctions among Vioxx users compared with the former standard-of-care drug, naproxen. Merck, the patent holder, responded that the difference was due to a "protective effect" it attributed to naproxen rather than a causative adverse effect of Vioxx.
One of the sources of empirical evidence that eventually discredited Merck's defense of Vioxx's safety was a pioneering data mining epidemiological study conducted by Graham et al. using the live electronic medical records of 1.4 million Kaiser Permanente of California patients. Their findings were presented first in a poster in 2004 and then in the Lancet in 2005. Two or three other contemporaneous epidemiological studies of smaller non-overlapping populations showed similar results. A rigorous 18-month prospective study of the efficacy of Vioxx's generic form in relieving colon polyps showed an "unanticipated" significant increase in heart attacks among study participants.
Merck's withdrawal of Vioxx was an early victory for Big Data, though it did not win the battle alone. What the controversy did do was demonstrate the power of data mining in live electronic medical records. Graham and his colleagues were able to retrospectively construct what was effectively a clinical trial based on over 2 million patient-years of data. The fact that EMR records are not as rigorously accurate as clinical trial data capture was rendered moot by the huge volume of data analyzed.
Today, the value of Big Data in epidemiology is unquestioned, and the current focus is on developing better analytics and in parallel addressing concerns about patient privacy. The HITECH Act and Obamacare are increasing the rate of electronic biomedical data capture, and improving the utility of such data by requiring the adoption of standardized data structures and controlled vocabularies.
We are witnessing the dawning of an era, and hopefully the start of the transformation of our broken healthcare system into a learning organization.
I believe if we reduce the time between intention and action, it causes a major change in what you can do, period. When you actually get it down to two seconds, it’s a different way of thinking, and that’s powerful. And so I believe, and this is what a lot of people believe in academia right now, that these on-body devices are really the next revolution in computing.
I am convinced that wearable devices, in particular heads-up devices of which Google Glass is an example, will be playing a major role in medical practice in the not-too-distant future. The above quote from Thad Starner describes the leverage point such devices will exploit: the gap that now exists between deciding to make use of a device and being able to carry out the intended action.
Right now it takes me between 15 and 30 seconds to get my iPhone out and do something useful with it. Even in its current primitive form, Google Glass can do at least some of the most common tasks for which I get out my iPhone in under five seconds, such as taking a snapshot or doing a Web search.
Closing the gap between intention and action will open up potential computing modalities that do not currently exist, entirely novel use case scenarios that are difficult even to envision before a critical mass of early adopter experience is achieved.
The Technology Review interview from which I extracted the quote raises some of the potential issues wearable tech needs to address, but the value proposition driving adoption will soon be truly compelling.
I'm adding some drill-down links below.
Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH.
One bit of good news about the Patient Centered Medical Home (PCMH) model: here is a study showing that in spite of considerable challenges to PCMH implementation, the transformations it embodies can be and are being implemented even in small primary care practices serving disadvantaged populations.
|ERCIM NEWS #98|
Twitter, like the Internet in general, has become a vast source of and resource for health care information. As with other tools on the Internet it also has the potential for misinformation to be distributed. In some cases this is done by accident by those with the best intentions. In other cases it is done on purpose such as when companies promote their products or services while using false accounts they created.
In order to help determine the credibility of tweets containing health-related content I suggest the using the following checklist (adapted from Rains & Karmikel, 2009):
Ultimately it is up to the individual to determine how to use health information they find on Twitter or other Internet sources. For patients anecdotal or experiential information shared by others with the same illness may be considered very credible. Others conducting research may find this a less valuable information source. Conversely a researcher may only be looking for tweets that contain reference to peer-reviewed journal articles whereas patients and their caregivers may have little or no interest in this type of resource.
Rains, S. A., & Karmike, C. D. (2009). Health information-seeking and perceptions of website credibility: Examining Web-use orientation, message characteristics, and structural features of websites. Computers in Human Behavior, 25(2), 544-553.
The altmetric movement is intended to develop new measures of production and contribution in academia. The following article provides a primer for research scholars on what metrics they should consider collecting when participating in various forms of social media.
If you participate on Twitter you should be keeping track of the number of tweets you send, how many times your tweets are replied to, re-tweeted by other users and how many @mentions (tweets that include your Twitter handle) you obtain. ThinkUp is an open source application that allows you to track these metrics as well as other social media tools such as Facebook and Google +. Please read my extensive review about this tool. This service is free.
You should register with a domain shortening service such as bit.ly, which will provide you with an API key that you can enter into applications you use to share links. This will provide a means to keep track of your click-through statistics in one location. Bit.ly records how many times a link you created was clicked on, the referrer and location of the user. Consider registering your own domain name and using it to shorten your tweets as a means of branding. In addition, you can use your custom link on electronic copies of your CV or at your own web site. This will inform you when your links have been clicked on. You should also consider using bit.ly to create links used at your web site, providing you with feedback on which are used the most often. For example, all of the links in this article were created using my custom bit.ly domain. In addition, you can tweet a link to any research study you publish to publicize as well as keep track of how many clicks are obtained. Bit.ly is a free service.
Another tool to measure your tweets is TweetReach. This service allows you to track the reach of your tweets by Twitter handle or tweet. It provides output in formats that can be saved for use elsewhere (Excel, PDF or the option to print or save your output by link). To use these latter features you must sign up for an account but the service is free.
Buffer is a tool that allows you to schedule your tweets in advance. You can also connect Buffer to your bit.ly account so links used can be included in your overall analytics. Although Buffer provides its own measures on click-through counts this can contradict what appears in bit.ly. This service is free but also has paid upgrade options available that provide more detailed analytics.
Google Scholar Citation Profile
You can set up a profile with Google Scholar based on your publication record. The metrics provided by this service include a citation count, h-index and i10-index. When someone searches your name using Google Scholar your profile will appear at the top before any of the citations. This provides a quick way to separate your articles from someone else who has the same name as you.
Google Feedburner for RSS feeds
If you maintain your own web site and use RSS feeds to announce new postings you can also collect statistics on how many times your article is clicked on. Feedburner, recently acquired by Google provides one way to measure this. You enter your RSS feed ULR and a report is generate, which can be saved in CVS format.
Journal article download statistics
Many journals provide statistics on the number of downloads of articles. Keep track of those associated with your publication by visiting the site. For example, BioMed Central (BMC) maintains an access count of the last 30 days, one year and all time for each of your publications.
Other means of contributing to the knowledge base in your field include participating on web-based forums or web sites such as Quora. Quora provides threaded discussions on topics and allows participants to both generate and respond to the question. Other users vote on your responses and points are accrued. If you want another user to answer your question you must “spend” some of your points. Providing a link to your public profile on Quora on your CV will demonstrate another form of contribution to your field.
Paper.li is a free service that curates content and renders it in a web-based format. The focus of my Paper.li is the use of technology in Canadian Healthcare. I have also created a page that appears at my web site. Metrics on the number of times your paper has been shared via Facebook, Twitter, Google + and Linked are available. This service is free.
Twylah is similar to paper.li in that it takes content and displays it in a newspaper format except it uses your Twitter feed. There is an option to create a personalized page. I use tweets.lauraogrady.ca. I also have a Twylah widget at my web site that shows my trending tweets in a condensed magazine layout. It appears in the side bar. This free service does not yet provide metrics but can help increase your tweet reach. If you create a custom link for your Twylah page you can keep track of how many people visit it.
Analytics for your web site
Log file analysis
If you maintain your own web site you can use a variety of tools to capture and analyze its use. One of the most popular applications is Google Analytics. If you are using a content management system such as WordPress there are many plug-ins that will add the code to the pages at your site and produce reports. WordPress also provides a built-in analytic available through its dashboard.
If you have access to the raw log files you could use a shareware log file program or the open source tool Piwik. These tools will provide summaries about what pages of your site are visited most frequently, what countries the visitors come from, how long visitors remain at your site and what search terms are used to reach your site.
All of this information should be included in the annual report you prepare for your department and your tenure application. This will increase awareness of altmetrics and improve our ability to have these efforts “count” as contributions in your field.